Carcinoid syndrome is a rare condition resulting from neuroendocrine tumors (NETs) that secrete vasoactive substances like serotonin. This report describes the case of a 61-year-old man with a history of chronic obstructive pulmonary disease (COPD) and hypertension who presented with new-onset angioedema, loss of consciousness, and a fall. He had been treated for COPD exacerbations during ER visits without improvement and was unaware of a prior mesenteric carcinoid tumor diagnosis from 2012. The next emergency evaluation revealed significant airway and facial edema necessitating intubation. Imaging and biopsy identified a well-differentiated grade 1 NET with extensive liver metastases. Laboratory tests showed elevated levels of serum serotonin, chromogranin A, and 24-hour urine 5-hydroxyindoleacetic acid (5-HIAA). Post-discharge, a PET scan confirmed metastatic lesions primarily in the liver and small bowel, with an unresectable mesenteric mass. The patient was treated with lanreotide and became symptom-free. This case underscores the need to consider carcinoid syndrome in patients with COPD presenting with unexplained respiratory symptoms, as timely diagnosis and treatment can significantly enhance patient outcomes.

We report an autopsy case of advanced esophageal cancer with multiple metastases that presented with a markedly high level of sIL-2R. An 83-year-old man was admitted to our hospital with a 1-week history of epigastric distress, appetite loss, and fatigue. Imaging examinations revealed a large liver tumor. Although the tumor markers for gastrointestinal and liver cancers were within normal limits, the sIL-2R level was extremely high (10,384 U/mL). The patient died immediately after admission due to the rapid course of the disease. An autopsy showed advanced esophageal cancer with multiple metastases, including the liver, lungs, and multiple lymph nodes. In histological examinations, esophageal cancer was a mixture of well- and poorly differentiated squamous cell carcinoma, in which poorly differentiated cancer cells expressed sIL-2R on immunohistochemical staining. However, we failed to detect positive staining for sIL-2R in the lymphocytes. Our findings revealed that solid tumors could express sIL-2R. Although sIL-2R is a tumor marker used for hematological malignancies, such as malignant lymphoma, this case report highlights the value of the measurement of sIL-2R levels in advanced solid tumors, including esophageal cancer. We concluded that sIL-2R has potential as a biomarker in advanced solid tumors for cancer staging and treatment response.

UNASSIGNED: This study aimed to investigate the usefulness of endoscopic ultrasound-guided tissue acquisition (EUS-TA) for diagnosing focal liver lesions in patients with a history of multiple primary malignant neoplasms.
UNASSIGNED: Among patients who underwent EUS-TA for focal liver lesions between 2016 and 2022, those with a history of multiple malignant neoplasms were included. A histologically confirmed malignant tumor within the past 5 years before EUS-TA was defined as a history of malignant neoplasm. The primary outcomes were diagnostic ability and adverse events of EUS-TA.
UNASSIGNED: This study included 16 patients (median age, 73 [33-90] years), the median tumor size was 32 (6-51) mm, 14 had a history of double malignant neoplasms, whereas two had triple malignant neoplasms. Malignant neoplasms were detected histologically or cytologically in all cases. Immunohistochemistry was performed in 75% (12/16), and the final diagnosis of EUS-TA was metastatic liver tumor in 12 patients, and primary malignant liver tumor in four patients. The primary site could be identified in 11 of 12 metastatic tumor cases. The diagnostic yield of EUS-TA was 100% (16/16) for differentiating benign and malignant tumors and 94% (15/16) for confirming the histological type including the primary site of metastatic lesions. No adverse events were associated with the procedure.
UNASSIGNED: EUS-TA is a useful diagnostic modality for focal liver lesions in patients with a history of multiple malignant neoplasms, allowing for the differential diagnosis of primary and metastatic tumors and identification of the primary site of metastatic lesions.

BACKGROUND: Oxaliplatin-based regimens are commonly used as adjuvant chemotherapy following surgery for colorectal cancer. Adverse events associated with oxaliplatin include blue liver, which is caused by sinusoidal dilation and diffuse peliosis hepatis. We report herein a case of localized peliosis hepatis closely resembling a metastatic liver tumor.
METHODS: The patient, a 50-year-old male, underwent a robotically assisted colectomy for rectosigmoid colon cancer, which was discovered when hematochezia occurred. The patient received a diagnosis of pStage IIIb and was treated with four courses of CAPOX as adjuvant chemotherapy starting at postoperative month 1. At postoperative month 4, contrast-enhanced computed tomography (CT) of the abdomen revealed a 20-mm, low-density area with heterogeneous internal structure in S6/7 of the liver. Abdominal ultrasound and gadolinium ethoxybenzyl-diethylenetriaminepentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI) findings led to a diagnosis of metastatic liver tumor, for which a laparoscopic partial hepatectomy was performed. The resected lesion was a dark reddish-brown nodule with indistinct margins that appeared to be continuous with the surrounding area. Histopathological analysis revealed severe, localized dilatation of the sinusoids and congestion consistent with the gross nodule. Based on these findings, localized peliosis hepatis associated with oxaliplatin-induced sinusoidal damage was diagnosed.
CONCLUSIONS: Localized peliosis hepatis associated with oxaliplatin use can be difficult to distinguish from a metastatic liver tumor on imaging studies.

An 82-year-old man developed a hypervascular renal tumor, 2 cm in size, and multiple liver tumors. Liver tumors had obscured tumor margins on ultrasonography. Positron emission tomography/computed tomography (PET/CT) showed no areas of avid radiotracer uptake in the liver. Routine pathological examination failed to demonstrate tumor cells in 9 tissue samples obtained from repeated core needle biopsies. Even a frozen section of the liver segment 8 tumor further failed to prove malignant cells, and an additive frozen section of the liver section 2 tumor finally proved atypical cells growing in tubular and solid fashions with eosinophilic cytoplasm. Tumors showed expansive growth patterns, were in direct contact with normal liver cells, had abundant micro-vessels, had only sparse hyalinized septa, and had no pale cells. Immunostaining revealed the tumor cells to be positive for CD10, CD117, and E-cadherin and negative for CK7, and PAX8, leading to the diagnosis of metastatic chromophobe renal cell carcinoma (chRCC) in the liver. Arginase-1 immunostaining clearly demarcated the boundary between the chRCC cells and normal hepatic cells. Diagnostic physicians should note that chRCCs are of low-grade malignancy despite their abundant intra-tumoral blood flow and can often pose imaging and pathologic diagnostic difficulties.

OBJECTIVE: This is a report of the first clinical implementation of 99mTc-labeled diethylene triamine pentaacetate-galactosyl human serum albumin (99mTc-GSA) single-photon emission computed tomography (SPECT) image-guided inverse planning into palliative radiotherapy (RT) for diffuse liver metastases.
METHODS: A 48-year-old man developed chemo-refractory diffuse liver metastases from thymic carcinoma characterized by abdominal pain and distension. Palliative RT was performed with a total dose of 20 Gy in five fractions using double arc volumetric modulated arc therapy to reduce the dose to functional liver defined by 99mTc-GSA SPECT images. His symptoms were immediately relieved after RT and did not experience radiation-induced liver disease. Both Functional Assessment of Cancer Therapy (FACT)-G and FACT-Hep total scores improved after 2 weeks of RT initiation and did not become worse than baseline scores.
CONCLUSIONS: The 99mTc-GSA SPECT image-guided palliative RT is an effective and safe treatment for patients with diffuse liver metastases.

BACKGROUND: The incidence of postoperative adhesions is directly correlated with the difficulty level of repeat hepatectomies. However, the incidence, location, and severity of postoperative adhesions in relation to hepatectomy-related operative procedures are yet unclear.
METHODS: First hepatectomy-induced hard dense adhesions were evaluated from the surgical records and/or videos of 168 patients who underwent second hepatectomies.
RESULTS: The incidence of postoperative hard dense adhesions around the liver was significantly associated with locations, such as the hepatic cut surface, dissected areas around the liver, and peri-incision peritoneum, and hepatectomy-related operative procedures, such as Pringle maneuver and cholecystectomy. The incidence of hard dense adhesions after dissection was higher around the right liver than in the left infraphrenic space. Further, the incidence of hard dense adhesions around the hepatoduodenal ligament or Morison pouch was greater than 30% even in patients who did not undergo Pringle maneuver, cholecystectomy, or hepatorenal ligament dissection. Although the incidence of hard dense adhesions of the peritoneum around the incision was higher after open hepatectomy than after laparoscopic hepatectomy, adhesion barrier use reduced the incidence of such adhesions in patients after open hepatectomy.
CONCLUSIONS: Hepatectomy-related operative procedures such as peri-hepatic dissection, Pringle maneuver and cholecystectomy are directly associated with postoperative hard dense adhesions. However, the incidence of postoperative hard dense adhesions around the hepatoduodenal ligament and Morison pouch was high even when the above-mentioned operative procedures were not performed. These findings may help inform clinical decisions regarding the indications and sites for adhesion barrier use during hepatectomies.

Liver resections have become the first-line treatment for primary and metastatic tumors and, therefore, are considered a core aspect of surgical training. This study aims to evaluate the learning curve of the extent and safety of liver resection procedures for patients with metastatic colorectal cancer.
This single tertiary center retrospective analysis includes 158 consecutive cases of small liver resection (SLR) (n = 107) and major liver resection (MLR) (n = 58) procedures. A cumulative sum control chart (CUSUM) method was used to investigate the learning curve.
The operative time, total blood loss level, and incidence of adverse effects showed a learning curve. For SLRs, the CUSUM curve for operative time and blood loss level peaked at the 19th and 17th case, respectively, while for MLRs, these curves peaked at the 28th and 24th case, respectively. The CUSUM curve for minor adverse effects (MAEs) and severe adverse effects (SAEs) showed a downward slope after the 16th and 68th procedures in the SLRs group and after the 29th and 39th procedures in the MLRs cohort; however, it remained within the acceptable range throughout the entire study.
SLR procedures were performed faster with less intraoperative blood loss and shorter postoperative stays than MLRs, and a higher number of completed procedures was required to gain stabilization and repeatability in the operating time and intraoperative blood loss level. In MLR procedures, the reduction of SAEs was accomplished significantly later than the stabilization of the operative time and intraoperative blood loss level.

A 60-year-old man was referred to our hospital for the evaluation and treatment of general malaise. Contrast-enhanced computed tomography detected sigmoid colon cancer that had invaded the bladder, multiple liver metastases, and a small intestinal tumor. Hartmann\'s procedure was performed, with partial bladder and small bowel resection. A pathological examination revealed that the patient had sigmoid colon cancer and a gastrointestinal stromal tumor. The biopsy findings of a tumor in segment 8 of the liver indicated the presence of adenocarcinoma, thereby indicating the origin of multiple liver metastases from sigmoid colon cancer. On chemotherapy, the tumors in liver segments 2/3 and 8 shrank. However, the tumor in segment 6 enlarged. Since radical resection of all metastatic liver tumors was possible, hepatectomy was performed 10 months after the initial surgery. A pathological examination revealed that the tumors in segments 2/3, 4, and 8 were adenocarcinomas and the tumors in segments 4, 6, and 7 had originated from the gastrointestinal stromal tumor. This suggested the coexistence of liver metastases from sigmoid colon cancer and the gastrointestinal stromal tumor. In cases involving multiple primary tumors, it is necessary to consider the possible coexistence of multiple metastases from different primary tumors.

BACKGROUND: The efficacy of resection of pancreatic cancer metastases has not been established. We here report two patients with long-term survival after resection of lung and liver metastases.
METHODS: The first patient underwent distal pancreatectomy for pancreatic cancer. One year later, she underwent partial hepatectomy for a single liver metastasis. She subsequently underwent pulmonary resections 7, 7.5, 9, and 10 years later for pulmonary metastases from pancreatic cancer. Thus, this patient underwent five surgeries for metastases, one for a liver metastasis and four for lung metastases. All of the tumors were pathologically diagnosed as metastatic pancreatic cancer. She is currently alive without new recurrence 10 years after the initial diagnosis. The second patient underwent pancreaticoduodenectomy for pancreatic cancer. Four years later, she underwent a thoracoscopic partial resection for lung metastasis. The tumor was similar to the pancreatic cancer on pathological examination. She is currently alive without new recurrences 6 years after the initial diagnosis.
CONCLUSIONS: Long-term survival can be achieved in some patients with pancreatic cancer by resection of metachronous liver or lung metastases.